“We have learned that the tobacco screening method is less important than the person who interacts with patients.” —Steven Bernstein, MD

Introduction

Hospital emergency departments (EDs), which have more than 120 million visits annually in the United States, offer a unique setting for screening patients who are at risk for specific conditions. Profiles featured recently on the Innovations Exchange focus on identifying individuals in the ED who are at increased risk of eating disorders , youth violence , and suicide. Researchers are also exploring other types of screening in this setting, including screening for sexually transmitted diseases and substance abuse. Dr. Jason Haukoos and his research team at the Denver Health Medical Center have developed an HIV screening instrument that is used in the ED. Dr. Steven Bernstein at the Yale School of Medicine has developed a screening and treatment intervention for tobacco users in the ED, as well as programs to train providers in tobacco cessation approaches.

Innovations Exchange: What led to your interest in screening patients in the ED?

Dr. Jason Haukoos: When I attended UCLA medical school in the mid-1990s, my mentor's clinical research focused on the evaluation and diagnosis of patients with HIV infection who came to the ED. After highly active antiretroviral therapy became available in 1995, HIV evolved from a disease linked to nearly certain death to a chronic disease. When I trained as a resident in emergency medicine from 1998 to 2001, a public policy goal was to identify patients with undiagnosed HIV infection and prevent transmission of the virus. High-risk patients routinely seek care in EDs, so HIV screening has become a core component of efforts to control the HIV epidemic in the United States.

Dr. Steven Bernstein: I trained in internal medicine and studied hematology–oncology nearly 30 years ago. I left that discipline to retrain in the ED. Working in the ED, I saw the same types of diseases that I saw when I was an internist and a hematology–oncology fellow. These included tobacco-related diseases such as lung cancer, chronic obstructive pulmonary disease, and emphysema. I noticed that we treated only acute problems in the ED, rather than looking at the underlying causes of those conditions. Although many people were working on the diagnosis of unrecognized HIV infections in the late 1980s and early 1990s, fewer people were working on identifying people at risk for tobacco-related diseases in the ED. I decided that I could contribute my efforts to reducing the number of people with tobacco-related diseases.

Do you see many at-risk patients in the ED?

Haukoos: Absolutely. Although the rate of AIDS has decreased since combination treatment became available in 1995, approximately 50,000 new infections occur annually. In addition, 250,000 individuals in the United States remain infected with undiagnosed HIV infections. These estimates have remained relatively unchanged over the past decade. The highest-risk individuals are still men who have sex with other men, but HIV is increasing most among racial and ethnic minorities. These are the same groups who tend to be uninsured, have limited access to primary care, and use the ED as their primary source of care. These factors and previous missed opportunities to diagnose HIV in the ED led the Centers for Disease Control and Prevention (CDC) and other public health organizations to focus attention on HIV screening in the ED.

Bernstein: For years, tobacco has been the leading cause of preventable death and illness in the United States. Although 19.8 percent of Americans continue to smoke, ED patients generally smoke more, with prevalence rates ranging from 21 percent in an affluent suburban community ED to 48 percent in urban areas.

Can you describe screening strategies for at-risk patients in EDs?

Haukoos: A major shift in HIV screening occurred in 2006, when the CDC changed its recommendation from offering HIV testing only to high-risk patients to offering HIV testing routinely to all patients ages 13 to 64. Recently the U.S. Preventive Services Task Force followed suit. Unfortunately, only a very small percentage of EDs in the United States have adopted such a broad screening practice. Prior to 2006, the CDC endorsed targeted screening based on risk factors such as an intravenous drug use, men who have sex with men, and high-risk heterosexual behaviors. The newer nontargeted approach recommended by the CDC is difficult for EDs to implement. In reality, few EDs can routinely offer screening to every patient who comes through the door. This approach also requires substantial resources. Integrating routine nontargeted HIV screening into ED operations results in thousands of HIV tests and only a modest number of newly diagnosed cases.

Bernstein: Typical tobacco screening strategies may consist of the doctor or nurse asking patients if they smoke, and making a referral to a State quitline or a local cessation program. Health care professionals may advise the patient to discuss smoking cessation with his or her primary care doctor.

In our ED at Yale, trained health promotion advocates from the community ask patients about tobacco use and other substance use. If they find a smoker who can give consent, they do a brief motivational interview and refer the patient to an intensive tobacco treatment program, a State quitline, a clinic, or a private physician. In our studies, research assistants are funded by grants to conduct screening and arrange referrals. We also train emergency physicians to conduct tobacco screening. It has been challenging to educate my ED colleagues that tobacco screening is within our scope of practice, and that we can't just leave that to our primary care colleagues.

Have you developed and tested a specific screening instrument?

Haukoos: A major aim of our Agency for Healthcare Research and Quality (AHRQ) grant that ended in 2013 was to develop a clinical prediction instrument that quantifies a patient's risk for HIV based on demographics, behavioral characteristics, and the use of HIV testing. We developed the Denver HIV Risk Score, which we validated externally and incorporated into our ED and urgent care service in 2011. The instrument is included in our broader electronic screening program that nurses use when patients enter the ED.

Bernstein: We have developed a brief “health quiz” that a nonclinician uses in the ED to screen patients at risk of substance use behaviors, including alcohol and tobacco use. The assessment tool is available in print and electronic formats for tablets and kiosks. In our validation studies, we found the tool to be very effective and reliable. It is a good case-finding method.

What has your research shown to be the most effective screening strategy?

Haukoos: Our first major study evaluating targeted screening (using the Denver HIV Risk Score) against nontargeted screening (as recommended by CDC) resulted in comparable numbers of newly diagnosed cases of HIV. It was notable, however, that only 551 patients in the targeted screening phase required HIV tests, compared with 3,591 patients in the nontargeted phase.

The targeted approach enables us to focus our limited HIV testing resources on the highest-risk patients. On average, we have to conduct approximately 1,000 HIV tests to find 1 positive test in nontargeted screening. That doesn't seem to be an efficient use of resources, when each rapid HIV test costs between $10 and $15.

Bernstein: My research in tobacco control has involved two randomized controlled trials looking at ED-initiated interventions to help tobacco smokers quit. The second trial, which was recently completed, involved a brief intervention of medication and counseling in low-income patients. The medication consisted of a 6-week supply of nicotine replacement therapy (patch and gum), with the first patch started in the ED. The counseling included motivational interviewing and an active referral to the Connecticut quitline. A study nurse also called participants in the intervention arm a few days after enrollment to check in and encourage them to continue treatment.

The 3-month followup showed that the participants in the brief intervention arm had quit rates of 12 percent, compared with about 5 percent in the control group. The quit rates were higher in this randomized controlled trial than in the first trial we conducted in New York, because we added enhancements to the intervention. These enhancements included administering the first dose of nicotine patch or gum in the ED and making the quitline referral in real time.

What lessons have you learned about implementing screening in the ED?

Haukoos: To make targeted HIV screening sustainable, it must be fully integrated into ED processes. Existing clinical staff should be trained in how to integrate the screening into their clinical workflows. Furthermore, policymakers who develop HIV screening recommendations may be unaware of the ED environment and the patients we serve. It's impractical to screen everyone for HIV for the following reasons:

The ED provides acute care rather than prevention services.

Many people cannot consent to be tested because their mental status is altered due to medical illnesses or substance abuse.

As many as 85 percent patients decline HIV testing because they don't perceive themselves as being at risk for HIV.

Regardless of the type of screening, some people with HIV infection will not be tested. So the question is this: How best do we use our scarce resources to identify the most patients with HIV infection? From my perspective, it's a targeted approach aimed at high-risk patients, and my team continues to conduct evaluation and implementation research to identify the best HIV screening strategies for use in EDs.

Bernstein: We have learned that the tobacco screening method is less important than the person who interacts with patients. We put a lot of time and effort into recruiting and training the right people. In order to talk to people about sensitive topics in a crowded ED, a person needs to have a personality that is nonjudgmental and empathic, and to be able to gain a patient's attention in a difficult environment.

Will you conduct further research to evaluate screening or treatment interventions?

Haukoos: Our research team is planning a large, multicenter clinical trial to evaluate thoroughly the following three HIV screening methods: targeted, using the Denver HIV Risk Score; targeted, using conventional methods (based on criteria such as injection drug use, high-risk sexual behaviors, or clinical signs of an immunocompromised state); and nontargeted, as recommended by the CDC in 2006. This multicenter study, which is known as The HIV Testing using Enhanced Screening Techniques in EDs (TESTED) Trial, is the first and largest of its kind. We hope that when the results are available in 2017, one screening method will emerge as more effective and efficient than the others. These results will inform our recommendations for broad implementation in ED settings.

Bernstein: Our next study will involve training doctors in hospital inpatient units at Yale to conduct tobacco interventions. Inpatient physicians will have access to comprehensive tobacco order sets that are integrated into the hospital's electronic health records system.

About Jason S. Haukoos, MD, MSc: Dr. Haukoos is the Director of Research and Clinical Research Fellowship for the Department of Emergency Medicine at Denver Health Medical Center, Denver, Colorado. He is an Associate Professor in the Department of Emergency Medicine at the University of Colorado School of Medicine, and in the Department of Epidemiology at the Colorado School of Public Health. Dr. Haukoos is a past recipient of an Individual National Research Service Award and an Independent Scientist Award from AHRQ. His research focus includes health services research and the epidemiology of emergency medical care, in particular HIV screening.

About Steven L. Bernstein, MD: Dr. Bernstein is a Professor of Emergency Medicine and Vice Chair, Academic Affairs, Department of Emergency Medicine, Yale School of Medicine, New Haven, CT. Dr. Bernstein's chief interest is in clinical trials of tobacco dependence treatment. He developed a screening and treatment intervention for tobacco users in the ED, as well as programs to train providers in tobacco control.

Disclosure Statements:

Dr. Haukoos reported that his institution received grants from AHRQ, the National Institute for Allergy and Infectious Diseases, and the Denver Health and Hospital Authority (his primary employer) that are relevant to the HIV research described in this perspective.

Dr. Bernstein reported that his institution received grants from the National Institutes of Health, the National Cancer Institute, the National Heart, Lung, and Blood Institute, and the National Institute on Drug Abuse that are relevant to the tobacco research described in this perspective. In addition, the American College of Emergency Physicians has supported his work in various ways, including dissemination of tobacco interventions among ED physicians, and revising and strengthening the tobacco treatment guideline in its 2010 policy statement on tobacco products.